Provider Demographics
NPI:1659344299
Name:DURICK, ROBERT J (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:DURICK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6205 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-3330
Mailing Address - Country:US
Mailing Address - Phone:330-726-6205
Mailing Address - Fax:330-726-5885
Practice Address - Street 1:6205 MARKET ST
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-3330
Practice Address - Country:US
Practice Address - Phone:330-726-6205
Practice Address - Fax:330-726-5885
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-01-76491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0593059Medicaid